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Background People with incomes below the Federal Poverty Level (FPL) do not qualify for health insurance subsidies and may not be eligible for Medicaid. Patients in this Medicaid Coverage Gap may have difficulty paying for their medications. Objective To estimate medication adherence and the prevalence of underinsurance among chronic condition patients in the Medicaid Coverage Gap. Methods A retrospective cohort study was conducted using 2014–2016 data extracted from the Medical Expenditure Panel Survey. The sample included non-elderly patients with prescription fills (≥2) for at least one of five chronic conditions (hypertension, hyperlipidemia, diabetes, depression and anxiety disorder) and income below the FPL. Medication adherence was measured using Medication Possession Ratio (MPR), and adjusted using patient demographics, health conditions, and health care utilization. The prevalence of underinsurance also was examined. Results Of the 316 patients, 60.4% were female, with an average age of 50, and an average of 3 health conditions. The weighted MPR was 72.0% and 44.6% had an adjusted MRP ≥80%. Nearly 80% of the patients were either continuously uninsured (21.6%) or underinsured (59.0%). Conclusions A significant proportion of chronic condition patients in Medicaid Coverage Gap were underinsured and less than half were adherent to their medications.

Objectives: (1)To compare Part D plan switching for users and nonusers of a pharmacy-led Medicare Part D consultation service and (2) to evaluate the effect of service use on chronic medication adherence. Methods: This was a longitudinal study, occurring in one independently owned community pharmacy in Iowa. Medicare Part D beneficiaries who used the service were compared to nonusers. Dispensing data were used to compare planswitching and the effect of service use on chronic medication adherence between service users and nonusers. Proportion of days covered (PDC) was used to evaluate medication adherence. Results: In the 2017 and 2018 plan year, 79 and 138 Medicare beneficiaries used the service, respectively. These individuals were compared to 849 Medicare beneficiaries and a random sample of 101 beneficiaries in respective years. The respective switching rates for service users in 2018 and 2019 plan year were 43% and 15.9%, compared to 4% switching rates in both years for nonusers. Using the Medicare Part D consultation yielded a statistically significant positive effect on switching in both plan years ( P values < .05) and a statistically significant positive effect on PDC between years ( P value Conclusion: The use of a pharmacist-led Medicare Part D consultation resulted in increased plan switching and improved chronic medication adherence.

Community pharmacies currently offer Medicare Part D consultation services to help eligible beneficiaries select prescription medication insurance. Despite these service offerings, there is a paucity of information on patient preferences for these service offerings and optimal service delivery from the patient perspective.The objectives of this study were to (1) evaluate patient expectations of and willingness-to-pay (WTP) for community pharmacy Medicare Part D consultation services, (2) identify components of Medicare Part D consultation services associated with service quality, and (3) explore differences in preferences and service expectations between services-experienced and service-naive patients.This was a qualitative exploratory study, with data collected using interviews and a follow-up supplemental survey with participants recruited from 5 community pharmacies across the state of Iowa participating in the Community Pharmacy Enhanced Services Network. A total of 17 patients contacted the research team for participation. Interviews were recorded and transcribed, with qualitative data analysis performed using template analysis guided by the SERVQUAL framework. Interview participants were invited to complete a supplemental survey. Descriptive statistics and frequencies were generated for survey items. Service-experienced and service-naive survey responses Pearson chi-square and Welch t tests were used to determine significant differences between service-experienced and service-naive responses for categorical and continuous variables, respectively.In total, all 17 patients who contacted the research team agreed to participate in interviews, with 8 service-experienced and 9 service-naive interviews completed. Template analysis identified 14 subdomains across the SERVQUAL domains. Similarities and differences in service preferences between groups were identified, focusing on patient-pharmacist trust, past service experience, and WTP. All interview participants completed supplemental surveys, with no statistically significant differences between service-experienced and service-naive participant characteristics identified.Service-experienced patients emphasized components of the service that contribute to service quality and generally reported higher WTP values. Many service-naive patients were unaware community pharmacies provided consultation services, suggesting that pharmacists may benefit from considering how services are offered to patients based on the specific preferences and expectations and consider ways to increase awareness of service offerings.

Background: There are many Medicare Part D plans, making it difficult for patients to choose the optimal plan. The decision to remain on current Medicare plans is reinforced by patient inertia and uncertainty associated with plan-switching decisions. By helping patients identify more cost-effective plans, pharmacists and pharmacy personnel have the ability to inform plan-switching decisions resulting in lower out-of-pocket (OOP) costs. Objectives: This study evaluates 1) patient experience with a pharmacy Medicare Part D consultation service and 2) potential out-of-pocket savings based on a patient’s best plan for 2019 compared to continuation of a patient’s 2018 Medicare Part D plan. Methods: This study was a retrospective descriptive analysis and took place at a single, independently owned community pharmacy. Patients received free individual consultations with a pharmacist that included a medication review and information on all available Part D plans. Patients were selected to receive the service using pharmacy software to identify potential inefficiencies in current Part D plans. Data on satisfaction and perceived pharmacist role in providing Medicare Part D information were collected via an in-person survey administered at the pharmacy. Potential out-of-pocket cost savings were determined using cost information provided for patient specific medication regimens entered into Medicare.gov, the online platform for Medicare Part D plan information. Results: Of the 318 patients identified, 79 used the consultation service. Out of 79 patients who used the service in fall of 2017, 44 completed the survey for a response rate of 56%. Patients generally reported good experiences with the service. Open-ended responses revealed patients utilize a variety of helpers for plan information and decisions. A subset of 14 patients were identified as having clear plan-switching decisions and were included in the cost-savings analysis. Conclusions: Patients using a free Medicare Part D plan consultation were satisfied with the service, suggesting that helpers were an important resource n their plan-selection process. Using the pharmacist-led Part D consultation may result in decreases in out-of-pocket cost savings due to identification of optimal Medicare Part D plans. Article Type: Note

Objectives To describe Iowa community pharmacies' experiences and satisfaction with the transition to Medicaid managed care and conduct a qualitative evaluation of the effect of Medicaid managed care on 3 independent community pharmacies. Design Cross-sectional descriptive study. Mixed methods were used: the quantitative phase was a mailed survey and the qualitative phase involved interviews. Setting and participants The mail survey was sent to Iowa-registered community pharmacies whose names and addresses were obtained from the Iowa Board of Pharmacy website. Interviews with pharmacists and other pharmacy staff were conducted at 3 Iowa independent community pharmacies. Outcome measures Pharmacy satisfaction and experiences with the Iowa Medicaid managed care program. Results The 265 returned surveys yielded a 27.4% response rate. Eight pharmacists and pharmacy staff were interviewed in the qualitative phase. Mean satisfaction with the Medicaid managed care organizations (MCOs) was 3.1 on a scale of 1-7, with 1 being extremely dissatisfied, and 7 being extremely satisfied. Respondents were most satisfied with the ease of joining the plans' pharmacy networks (mean = 4.1) and least satisfied with the availability of payment for nondispensing-related services (2.3), plans' communication with patients (2.7), and plans' communication with pharmacies (3.0). Pharmacies also reported problems with patients' access to prescriptions. The MCOs ranked lowest in satisfaction when compared with the largest private payer, the largest Medicare Part D plan, and the previous state-run Medicaid program. The themes that emerged from the interviews were as follows: confusion caused by multiple MCOs, plan-communication challenges, product-coverage challenges, problems related to durable medical equipment, and payment challenges. Conclusion The transition from a state-run fee-for-service Medicaid program to Medicaid managed care in Iowa created many challenges for community pharmacies. Different procedures and product coverage across the 3 MCOs were particularly problematic.

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Introduction Excess spending and poor quality in the US healthcare system has led to proliferation of performance-based payment models. These models have the potential to enhance value by creating a meritocratic system whereby providers delivering the best patient care are rewarded, while providers failing to provide such care are given incentives to improve. However, early experience suggests that unless these systems are appropriately designed, payments can be withheld from high performers, bonuses paid to low performers, and health disparities can be worsened. Performance-based payments are new to community pharmacies, and opportunity exists to strengthen pharmacy value measurement and potentially avoid problems observed with other performance-based payment models. Model construction and application This article describes the process by which a framework to assess community pharmacy value was developed, then applies the framework to produce a draft composite pharmacy performance measure. The pharmacy value framework addresses potential shortcomings of existing community pharmacy performance measures through four key principles: 1) theory-based quality and spending measures, 2) scoring which accounts for measure reliability, 3) full risk-adjustment, and 4) a value matrix to identify high and low value pharmacies. Based on these principles, a draft community pharmacy composite performance measure was developed, and was successful in dividing community pharmacies into high, typical, and low value categories. Conclusion By using this framework to develop future composite measures, payers may find closer alignment between performance-based payments and actual pharmacy performance. This early work is intended to encourage further research into the establishment of a scientifically firm foundation for pharmacy performance measurement. More testing is needed to determine reliability, validity, and comparative superiority of any composite measure derived from this framework before it is used to support performance-based pharmacy payment models.

Objectives To examine average prescription gross margin (GM) for prescriptions and to evaluate the prevalence of below-cost reimbursement for generic prescriptions across different third-party payers and therapeutic categories. Design A retrospective descriptive study using 2015 dispensing data from a single independently owned pharmacy in Iowa. To calculate GM, the pharmacy's actual acquisition cost was subtracted from the third-party reimbursement rate for each generic prescription. The frequency of negative GMs was calculated for the top 6 plans and the top 10 therapeutic categories by prescription volume. Setting A single, independently owned community pharmacy in Iowa. Participants Prescription dispensing records for the pharmacy's largest private and public payers by prescription volume. Intervention Gross margins were calculated on a payer and United States Pharmacopeia (USP) medication category level. Main outcome measures GM for generic prescriptions reimbursed under cost for specific payers and USP medication categories. Results The 2015 prescription volume for the study pharmacy was 70,866 prescriptions, of which 88% were generic. For all prescriptions, the mean GM was $6.63 per prescription, and the median GM was $3.49 per prescription. Generic medications had a mean GM of $4.66 (median, $2.86), and brand name medications had a mean GM of $21.83 (median, $16.15). The percentage of generic prescriptions paid below acquisition cost was 15.1% overall and ranged from 4.1% for Iowa Medicaid to 25.9% for one of the private payers. The most common USP medication category by prescription volume was cardiovascular agents, representing 25.2% of generic prescriptions. For the 10.9% of these prescriptions reimbursed below cost, the mean GM was –$6.80. The 2 USP medication categories with the largest negative mean GM for generic prescriptions were analgesics and anticonvulsants, with mean GMs of –$10.10 and –$11.30, respectively. Conclusion The current maximum allowable cost–based reimbursement system often results in inadequate payment for generic prescription drugs. The amount of underpayment varies substantially by payer and therapeutic class.

Medicare Part D beneficiaries tend not to switch plans despite the government’s efforts to engage beneficiaries in the plan switching process. Understanding current and alternative plan features is a necessary step to make informed plan switching decisions. This study explored beneficiaries’ plan switching using a mixed-methods approach, with a focus on the concept of information processing. We found large variation in beneficiary comprehension of plan information among both switchers and nonswitchers. Knowledge about alternative plans was especially poor, with only about half of switchers and 2 in 10 nonswitchers being well informed about plans other than their current plan. We also found that helpers had a prominent role in plan decision making—nearly twice as many switchers as nonswitchers worked with helpers for their plan selection. Our study suggests that easier access to helpers as well as helpers’ extensive involvement in the decision-making process promote informed plan switching decisions.

The aim of this study was to determine the issues patients worry about when making decisions about cancer treatment. A total of 5,044 colorectal and lung cancer patients from the Cancer Care Outcomes Research and Surveillance Consortium reported their level of worry about (1) treatment side effects, (2) treatment costs, (3) time away from family, (4) time away from work, and (5) transportation to treatment sites. Using multivariable logistic regression, we evaluated the association of sociodemographic, clinical, and psychosocial variables with worry. Overall, 75 % of patients worried about side effects of treatments; 40 %, the cost of treatment; 50 %, time away from family; 52 %, time away from work; and 22 %, about transportation. In multivariable analyses, across all worry domains, older patients had lower odds of reporting worry (p values

Objectives To describe and identify significant relationships among pharmacy service use, general and service-specific patient satisfaction, pharmacy patronage motives, and marketing awareness in a service-oriented, independent community pharmacy. Design Cross-sectional study. Setting Midwest United States during May through July 2011. Participants Stratified random sample of 500 participants. Intervention Self-reported questionnaire mailed to participants. Main outcome measures Patient satisfaction, pharmacy service use, patronage motives, marketing awareness, and demographics. Results Study participants were mostly satisfied with the pharmacy services on global and service-specific measures. Patronage motives of relationships, pharmacy atmosphere, and quality previous experience were associated with increased pharmacy service use at the study pharmacy, while a unique service patronage motivation was associated with decreased pharmacy service use at the study pharmacy. Participants citing pharmacy atmosphere and personnel competency as patronage motives did not use pharmacies other than the study pharmacy more often, whereas participants citing unique services as a patronage motive used pharmacies other than the study pharmacy more often. Direct marketing awareness increased pharmacy service awareness but not use. Conclusion Offering unique services may not be enough to bring in patients loyal to all services provided in a pharmacy. Pharmacists should focus on developing strong relationships with patients and conveying competence when delivering appropriate, quality pharmacy services in a professional pharmacy atmosphere.

Our objective was to identify factors related to receipt of the recommended number of well-child visits in insured children. We hypothesized parent insurance status would be related to receipt of well-child visits, with those with uninsured parents more likely to have fewer visits than recommended. Data for the study came from the 2007 Medical Expenditure Panel Survey-Household Component. The sample included children

To examine how pharmacy bargaining activities affect reimbursement rates in Medicare Part D prescription drug plan (PDP) contracts, controlling for pharmacy quality attributes, market structures, and area socioeconomic status.Cross-sectional study.Six Medicare regions throughout the United States between October and December 2009.Random sample of 1,650 independent pharmacies; 321 returned surveys containing sufficient responses for analysis.Pharmacies were surveyed regarding PDP reimbursement rates, costs, and cash prices of two popular prescription drugs (atorvastatin calcium [Lipitor-Pfizer] and lisinopril, 1-month supply of a common strength), as well as pharmacy bargaining activities and quality attributes. Data also were used from the National Council for Prescription Drug Programs pharmacy database, the 2000 U. S. Census, and the 2006 Economic Census on local market structures and area socio-economic status.PDP reimbursement rates.For the brand-name drug atorvastatin calcium, the PDP reimbursement was positively related to a pharmacy's request for a contract change (β = 0.887, P0.05), whereas other bargaining activities were not significantly related to PDP reimbursement. However, for the generic drug lisinopril, no bargaining activities were found to be significantly related to the PDP reimbursement.Pharmacy request for a contract change was associated with higher reimbursement rates for the brand-name drug atorvastatin calcium in PDP contracts, after controlling for pharmacy quality attributes, local market structures, and area socioeconomic status; this finding likely applies to other brand-name drugs because of the structure of the contracts. Our results suggest that independent pharmacies are more likely to acquire higher reimbursement rates by engaging in active bargaining with third-party payers.

Objectives To examine how prescription drug access and use of prescription cost-saving measures changed after Medicare Part D was implemented and to determine their predictors in Medicare beneficiaries with different insurance types. Design Repeated cross-sectional study. Setting United States in 2005 and 2007. Patients Medicare beneficiaries aged 65 years or older (n = 1,220 in 2005 and n = 1,024 in 2007). Intervention Web-based surveys using nonprobability samples. Main outcome measures Access to prescription drugs and use of seven cost-saving measures. Results Significantly fewer participants stopped taking a prescription because of cost, applied to an assistance program, received free prescription samples, and had limited prescription access in 2007 compared with 2005. Use of cost-saving measures by Medicare Part D patients was more comparable with that by uninsured participants than patients with employer-based drug coverage. One-third of all participants and almost one-half of Medicare Part D participants had requested a less expensive prescription. Among those participants, 70% received a less expensive prescription and most thought it worked about the same as the more expensive prescription. Conclusion Prescription drug access and use of cost-saving measures improved somewhat following the implementation of Medicare Part D, but some access problems continued to exist for Part D participants. Requests for less expensive prescriptions were common and frequently resulted in satisfactory switches.

OBJECTIVE: The barriers to provider visits for asthma in insured children are not well understood. Our objective was to examine the relationship between parent, family, and child attributes and asthma visits in insured children. METHODS: This retrospective, cross-sectional analysis of 2007 Medical Expenditure Panel Survey-Household Component data included insured children 0-17 years old reported to have active asthma. We summed the number of provider visits during which asthma was treated or diagnosed to represent the frequency of asthma visits during the year. Probit models were used to estimate the relationship between parent, family, and child attributes and asthma visits. RESULTS: Seventy percent of the 542 children did not have an asthma visit during the year. Children with parents employed full time were 16 percentage points less likely to have an asthma visit than children whose parents were not working ( P = .01). CONCLUSION: Many insured children go more than a year without seeing a provider for their asthma, signaling that insurance is not sufficient to guarantee children will receive asthma monitoring. The attributes related to asthma visits suggest potential barriers that providers might want to consider to increase participation in asthma visits.

Objectives To assess changes in prescription gross margin from 2008 to 2011 using a random sample of prescriptions, analyze changes in prescription gross margin from 2008 to 2011 using a market basket of prescription drugs, and investigate impact of changes in prescription mix from 2008 to 2011 on prescription gross margins. Design Longitudinal, retrospective, descriptive case study. Setting Single independent pharmacy in Iowa City, IA, from March and April of 2008–11. Participants Prescription dispensing records for the pharmacy's largest private and Part D payers by prescription volume, as well as Medicaid and cash payers. Intervention Random sampling and market basket approaches were used for gross margin calculation. Main outcome measures Prescription gross margins and generic dispensing rate. Results Data were collected for 2,400 prescription records for the random sample and 4,860 prescriptions for the market basket sample. The median random sample and market basket gross margin dollars (GMDs) from 2008 to 2011 decreased from $9.55 to $7.22 and from $9.60 to $8.50, respectively. The percent of dispensed prescriptions that was generic increased from 62.65% in 2008 to 73.64% in 2011, and GMDs were significantly lower for generic products. Conclusion Third-party prescription drug gross margins in the study pharmacy varied substantially by payer and decreased over time. Pharmacies must continue to monitor changes in prescription margins and investigate ways to enhance alternative revenue sources to maintain profitability.

Background Most U.S. states had over 50 Medicare Prescription Drug Plans (PDPs) in 2007. Medicare beneficiaries are expected to switch Part D plans based on their health and financial needs; however, the switching rate has been low. Such consumer inertia potentially has negative effects on both beneficiaries and the insurance market, resulting in a critical need to investigate its cause. Objectives To 1) describe how Medicare beneficiaries who were satisfied with their current Part D plan differed from those who were not satisfied; 2) examine the effect of switching costs on consideration of switching among Medicare beneficiaries who were dissatisfied with their current Part D plan. Methods Data from the 2007 Prescription Drug Study supplement to the Health and Retirement Study (HRS) survey were used in this study. The satisfied and dissatisfied groups were compared in terms of cost variables, switching costs, and perception of Part D complexity. Structural equation modeling was used to examine relationships among switching costs, Part D complexity, cost variables, and consideration of switching for beneficiaries who were dissatisfied with their current Part D coverage. Results Out of 467 participants, a total of 255 (54.6%) were satisfied with their current Part D plan. The satisfied group paid lower out-of-pocket costs ($50.63 vs. $114.60) and premiums ($30.88 vs. $40.77) than the dissatisfied group. They also had lower switching costs. Only 11.3% of the dissatisfied beneficiaries switched plans. Among respondents who were dissatisfied with their current plan, those who perceived Part D as complex had high switching costs and were less likely to consider switching plans. Out-of-pocket cost did not have a statistically significant association with consideration of switching. Conclusions Medicare beneficiaries who were satisfied with their current Part D plans had lower out-of-pocket costs and premiums as well as higher switching costs. Among beneficiaries who were dissatisfied with their current Part D plan, those who had higher switching costs were less likely to consider switching Part D plans.

Objectives To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy. Methods Three years (2008–10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit. Results 7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included. Conclusions Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Purpose To assess patients' experiences with cancer care, ratings of their quality of care, and correlates of these assessments. Patients and Methods For 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care). Results English-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05). Conclusion Patients' reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients' experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.

To examine whether local area pharmacy market structure influences contract terms between prescription drug plans (PDPs) and pharmacies under Part D.Data were collected and compiled from four sources: a national mail survey to independent pharmacies, National Councilfor Prescription Drug Programs (NCPDP) Pharmacy database, 2000 U.S. Census data, and 2006 Economic Census data.Reimbursements varied substantially across pharmacies. Reimbursement for 20mg Lipitor (30 tablets) ranged from $62.40 to $154.80, and for 10mg Lisinopril (30 tablets), it ranged from $1.05 to $18. For brand-name drug Lipitor, local area pharmacy ownership concentration had a consistent positive effect on pharmacy bargaining power across model specifications (estimates between 0.084 and 0.097), while local area per capita income had a consistent negative effect on pharmacy bargaining power across specifications(-0.149 to -0.153). Few statistically significant relationships were found for generic drug Lisinopril.Significant variation exists in PDP reimbursement and pharmacy bargaining power with PDPs. Pharmacy bargaining power is negatively related to the competition level and the income level in the area. These relationships are stronger for brand name than for generics. As contract offers tend to be non-negotiable, variation in reimbursements and pharmacy bargaining power reflect differences in initial insurer contract offerings. Such observations fit Rubinstein's subgame perfect equilibrium model.Our results suggest pharmacies at the most risk of closing due to low reimbursements are in areas with many competing pharmacies. This implies that closures related to Part D changes will have limited effect on Medicare beneficiaries' access to pharmacies.

Objective – To examine whether local area pharmacy market structure influences contract terms between prescription drug plans (PDPs) and pharmacies under Part D. Data – Data were collected and compiled from four sources: a national mail survey to independent pharmacies, National Council for Prescription Drug Programs (NCPDP) Pharmacy database, 2000 U.S. Census data, and 2006 Economic Census data. Results – Reimbursements varied substantially across pharmacies. Reimbursement for 20mg Lipitor (30 tablets) ranged from $62.40 to $154.80, and for 10mg Lisinopril (30 tablets), it ranged from $1.05 to $18. For brand-name drug Lipitor, local area pharmacy ownership concentration had a consistent positive effect on pharmacy bargaining power across model specifications (estimates between 0.084 and 0.097), while local area per capita income had a consistent negative effect on pharmacy bargaining power across specifications(−0.149 to −0.153). Few statistically significant relationships were found for generic drug Lisinopril. Conclusion – Significant variation exists in PDP reimbursement and pharmacy bargaining power with PDPs. Pharmacy bargaining power is negatively related to the competition level and the income level in the area. These relationships are stronger for brand name than for generics. As contract offers tend to be non-negotiable, variation in reimbursements and pharmacy bargaining power reflect differences in initial insurer contract offerings. Such observations fit Rubinstein's subgame perfect equilibrium model. Implication – Our results suggest pharmacies at the most risk of closing due to low reimbursements are in areas with many competing pharmacies. This implies that closures related to Part D changes will have limited effect on Medicare beneficiaries’ access to pharmacies.

As Medicare Part D contracts apply pressure on the profitability of independent pharmacies, there is concern about their owners' willingness to sign such contracts. Identifying factors affecting independent pharmacy owners' satisfaction with Medicare Part D contracts could inform policy makers in managing Medicare Part D.(1) To identify influences on independent pharmacy owners' satisfaction with Medicare Part D contracts and (2) to characterize comments made by independent pharmacy owners about Medicare Part D.This cross-sectional study used a mail survey of independent pharmacy owners in 15 states comprising 6 Medicare regions to collect information on their most- and least-favorable Medicare Part D contracts, including satisfaction, contract management activities, market position, pharmacy operation, and specific payment levels on brand and generic drugs.Of the 1649 surveys mailed, 296 surveys were analyzed. The regression models for satisfaction with both the least and the most-favorable Part D contracts were significant (P0.05). A different set of significant influences on satisfaction was identified for each regression model. For the most-favorable contract, influences were contending and equity. For the least-favorable contract, influences were negotiation, equity, generic rate bonus, and medication therapy management (MTM) payment. About one-third of the survey respondents made at least 1 comment. The most frequent themes in the comments were that Medicare Part D reimbursement rate is too low (28%) and that contracts are offered without negotiation in a "take it or leave it" manner (20%).Equity, contending, negotiation, generic rate bonus, and MTM payments were identified as the influences of independent pharmacy owners' satisfaction toward Medicare Part D contracts. Generic rate bonus and MTM payment provide additional financial incentives to less financially favorable contracts and, in turn, contribute to independent pharmacy owner's satisfaction toward these contracts.

Objectives: Quantify risk factors for self-reported adverse drug events (ADEs) after the implementation of Medicare Part D, quantify self-reported ADEs before and after Medicare Part D and quantify the association between self-reported ADEs and increased use of prescription medication. Methods: The design was a longitudinal study including an internet survey before Medicare Part D in 2005 (n=1220) and a follow-up survey in 2007 (n=1024), with n=436 responding to both surveys. Harris Interactive® invited individuals in their online panel to participate in this study. Individuals who were 65 or older, English speakers, US residents and enrolled in Medicare were included. Data collected and used in analysis included self-reported ADE, socio-demographics, self-rated health, number of medications, symptoms experienced, concern and necessity beliefs about medicines, number of pharmacies, and whether doses were skipped or stopped to save money. Results: In 2007, reporting an ADE was related to concern beliefs, symptoms experienced and age. ADEs were experienced by 18% of respondents in 2005 and 20.4% in 2007. The average number of medications increased from 3.82 (SD=2.82) in 2005 to 4.32 (SD=3.20) in 2007 (t= -5.77, p

Background Incentive-based prescription drug cost sharing can encourage seniors to use generic medications. Little information exists about prescription drug cost sharing and generic use in employer-sponsored plans after the implementation of Medicare Part D. Objectives To compare prescription drug cost sharing across prescription insurance type for Medicare beneficiaries after Medicare Part D, to assess the impact of that cost sharing on the number of medications used, and to examine how generic utilization rates differ before and after Medicare Part D and across the type of insurance. Methods This longitudinal study of Medicare beneficiaries aged 65 years and older used Web-based surveys administered in 2005 and 2007 by Harris Interactive ® to collect information on prescription drug coverage and medication use. Co-payment plans were categorized as low, medium, or high co-payment plans. Multiple regression was used to assess the impact of co-payment rank on the number of prescription drugs. t -Tests and analysis of variance were used to compare generic use over time and between coverage types. Results One thousand two hundred twenty and 1024 respondents completed the baseline and follow-up surveys, respectively. Among 3-tier co-payment plans, brand drug co-payments were higher for Part D plans ($26 for preferred brand and $55 for nonpreferred brand) than employer-based plans ($20 for preferred brand and $39 for nonpreferred brand). Co-payment was not a significant predictor for the number of prescription drugs. Generic use was lowest among beneficiaries in employer plans both before and after Part D. In 2007, generic use among beneficiaries with Part D was not significantly different from the generic use for beneficiaries with no drug coverage. Conclusions Medicare beneficiaries in Part D had higher cost sharing amounts than those with employer coverage, but higher cost sharing was not significantly linked to lower prescription use. Generic use for Part D beneficiaries was higher than that for beneficiaries with employer coverage but the same as that for beneficiaries without drug coverage.

To (1) describe prescription drug cost sharing and benefit structures faced by seniors before implementation of the Medicare drug benefit, (2) examine the relationship between prescription drug benefit structure and prescription drug use by seniors prior to Medicare drug benefit, and (3) examine factors predicting intention to enroll in the Medicare drug benefit.Cross-sectional study.Internet-based survey administered on behalf of the researchers by Harris Interactive in October 2005.Harris Interactive maintains a panel of individuals who have opted to participate in online surveys. Individuals from this panel who were English speaking, 65 years of age or older, U.S. residents, and enrolled in Medicare were invited to participate.The survey collected information on prescription coverage, prescription use, intention to enroll in the Medicare drug benefit, health status, and demographics.Number of prescriptions used by a beneficiary in the month before the survey and the intention of the beneficiary to enroll in the Medicare drug benefit.Beneficiaries were enrolled in plans with a wide variety of benefit structures and cost-sharing amounts. Prescription drug use fell with higher copayment ranks and average coinsurance but not at the P0.05 level. Among poorer individuals, the relationship between copayment rank and use was significant. Individuals reporting worse health status and a higher number of prescriptions indicated greater intention to enroll in the Medicare drug benefit, suggesting possible adverse selection.Prescription use decreased as cost sharing increased with mixed significance. There was evidence of potential adverse selection in the Medicare drug benefit.

Background Medicare Part D took effect in January 2006 with requirements for prescription drug plans to provide medication therapy management (MTM) services to targeted Medicare beneficiaries. The use of Medicare Part D MTM is voluntary by Medicare beneficiaries and no research evidence is available that can inform policy makers of the beneficiary and provider access-level circumstances under which older adults are more likely to demand MTM-like services. Objective The objective of this study was to describe the effects of the characteristics of older adults and their provider access on the demand for MTM services using data from a unique pre-Medicare Part D program for Medicare-eligible older adults in Iowa. Methods A retrospective cohort study using enrollment, claims, and provider data from the Iowa Priority Prescription Savings (IP) Program. The dependent variable was whether the IP members obtained the MTM service offered by the program. Logistic regression was used to assess whether IP member characteristics and their provider access affected the probability of the IP member to obtain the MTM service. Results Demand for the service varied with IP member age, gender, monthly number of drugs taken, monthly prescription drug spending, self-reported health status, having alternative insurance, and seeing multiple physicians. Increased access to pharmacies promoting the service increased IP member demand. Conclusion The demand for MTM-like services varies with the characteristics of older adults and their access to providers that promote the service. Older adults who view themselves as sicker and those with more complex medication regimens appear more likely to demand a service, suggesting that the benefits of the service are either more important or more recognizable to them. However, it appears that older adults require contact with pharmacies that promote MTM services to recognize this value.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides a prescription drug benefit for Medicare-eligible seniors that includes access to medication therapy management services (MTMS) through pharmacists. We theorize that local community pharmacy market competition affects the decision of individual community pharmacies to provide MTMS. Our model suggests that MTMS services are more apt to be supplied in markets at the extremes of community pharmacy concentration (very low and very high). We found that local community pharmacy competition affected the service choices made by the pharmacy decision-makers willing to provide MTMS in a manner consistent with our theory. As a result, patient access to MTMS services depends on both (1) patient access to pharmacies willing to provide MTMS and (2) the level of local community pharmacy competition.

Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. As part of the coverage, medication therapy management services (MTMS) are mandated for beneficiaries with chronic diseases who take multiple medications covered under part D and who are likely to incur annual costs that exceed a specified level.To predict the behavioral intention of pharmacists to provide Medicare medication therapy management services (MTMS) using the theory of planned behavior (TPB) and to determine the relationship between pharmacists' characteristics and intention to provide MTMS.The population for this cross-sectional descriptive study consisted of all community pharmacists in Iowa. Data collection occurred through a self-administered anonymous mail survey. Two surveys each were mailed to 500 pharmacies selected through a stratified random sample, 1 survey for the pharmacy manager and 1 survey for a staff pharmacist if applicable. Descriptive statistics and scale reliability were calculated for each of the 4 TPB scales (attitude, subjective norm, perceived behavioral control, and intention). Linear regression was used to predict intent as a function of the other 3 TPB factors, demographic factors, experience, and type of pharmacy.Out of 212 surveys received, 203 had usable data. The usable response rate ranged from 21% to 41%. Pharmacists' intent to provide MTMS was generally positive but varied in strength with a mean score of 22.47 (+/-4.00) and a range of 7-30. Pharmacists mostly agreed that they had appropriate training to provide MTMS but lacked time and support. The linear regression analysis found the constructs of attitude, subjective norm, and perceived behavioral control to be significant predictors of intent (P.05). Pharmacists with stronger intent to provide MTMS were those who felt they had more control over providing MTMS, felt their peers approved of the provision of MTMS, and had a positive attitude about providing MTMS. Type of pharmacy and pharmacist demographic variables were not significant predictors of intent to provide MTMS.Pharmacists showed generally positive intent to provide MTMS. Perceived behavioral control, subjective norm, and attitude were significant predictors of intent (P.05). Strategies to help pharmacists provide MTMS should focus on finding time and support to provide MTMS rather than individual educational needs.

To examine PharmD students' knowledge about Medicare Part D and their attitudes toward and intention to provide Medicare medication therapy management services (MTMS).Fourth-professional year students were given a self-administered survey instrument that assessed: (1) knowledge about Medicare Part D; (2) attitudes, perceived behavioral control, subjective norms, and intention to provide Medicare MTMS; and (3) demographic and experience information.Ninety-five students responded for a response rate of 94%. Students showed good basic knowledge about Medicare Part D, with a mean score of 94%. Almost 60% of students agreed that they intended to provide Medicare MTMS, but agreement dropped to 37% when they were asked if they were willing to take initiative to provide MTMS.The lack of willingness to take initiative to provide Medicare MTMS suggests that colleges and schools of pharmacy must strengthen efforts to encourage students to take on the role of service provider.